The Fourth Horseman: A Short History of Epidemics, Plagues and Other Scourges by Andrew Nikiforuk
Fourth Estate, 200 pp, £14.99, April 1992, ISBN 1 85702 051 0

In Time of Plague: The History and Social Consequences of Lethal Epidemic Disease edited by Arien Mack
New York, 272 pp, $35.00, November 1991, ISBN 0 8147 5467 8

Miasmas and Disease: Public Health and the Environment in the Pre-Industrial Age by Carlo Cipolla, translated by Elizabeth Potter
Yale, 101 pp, £16.95, March 1992, ISBN 0 300 04806 8

International Journal of STD and Aids. Vol. II, Supplement I: Aids and the Epidemics of History edited by Harry Rolin, Richard Creese and Ronald Mann
Royal Society of Medicine, January 2000, ISBN 0 00 956462 4

Seventy-four years ago a viral pandemic began in America, most likely on a pig farm in Iowa. Fifteen months later it had killed over eighteen million people, 1 per cent of the world’s population, as many as died in two world wars, almost ten times as many as have died in a decade of Aids. The virus, transmitted by airborne mucus and saliva, spread via coughs and sneezes. In San Francisco and other American cities public health officials warned against all body contact, including shaking hands; ordinances were issued forbidding citizens from appearing in public places without face masks. Possibly because of such measures there were only a few thousand deaths in San Francisco during the first year of the pandemic, but elsewhere, including Europe, the toll was much higher. In Alaska and Central Africa and Oceania entire communities were wiped out. In India, it is estimated, the virus claimed twelve million victims – 4 per cent of the population.

In statistical terms it was the greatest natural disaster since the Black Death, yet the Great Influenza Epidemic (or Pandemic) of 1918-19 has vanished from public consciousness. Unlike the war that immediately preceded it, the flu has left scarcely a trace in modern literature; historical accounts of it are sparse; one of its few chroniclers claimed that ‘the Spanish Lady inspired no songs, no legends, no work of art.’ There are, in fact, two or three short stories about it – reclaimed for lit crit by Barbara Fass Leavy in To Blight With Plague – plus a couple of book-length historical accounts and a handful of articles in scholarly periodicals (the African response is considered, inter alia, by Terence Ranger in Epidemics and Ideas). And there is Oliver Sacks’s Awakenings, on the outbreak of encephalitis lethargia that was triggered by the flu. But that’s it. Most people know more about smallpox, or the plague of 1665. Why should this be? The flu was unprecedented in its virulence and global in its effects. Yet it came and went like a noxious fog, like something outside human understanding.

Aids (or HIV-disease, as medical authorities now tend to call it) – which, according to estimates from the World Health Organisation, has caused the deaths of two million people, has, by contrast, engendered a scientific and lay literature so vast that it defies easy summation or analysis. WHO estimates that several thousand people become infected with one or other of the strains of HIV every day. This figure is almost matched by the number of articles, bulletins, statistical records, conference papers, research proposals, press reports, newsletters and books about Aids and HIV that appear in the same space of time. A single issue of the Aids Newsletter, for example – itself just one of many such newsletters – summarises more than a hundred published items in European languages alone.

Of course it is not just a question of the scale of scholarly and journalistic production: the multiple epidemics have changed social arrangements. But these changes are, to a large extent, the result of the unprecedented level of information exchange. Aids has been the occasion for previously unheard-of co-operation between marginalised groups and the institutions of public health; it has given rise to a genre shift, a novel interpenetration of scientific and popular discourse. It has brought about what seems to be a permanent alteration in public perception and ways of talking about sex. There have been significant, if not permanent modifications in sexual practice and rapid innovations in public health policy in both industrialised and non-industrialised countries. And all this with the exact cause of the disease still in dispute, not much in the way of effective treatment, no vaccine and no cure. Although the full social and demographic effects have yet to make themselves felt, the disease has already entered the culture at so many levels that it is hard to imagine that it could be forgotten, as the Great Flu has been, even if a cure – or more probably a vaccine (since viruses generally cannot be extirpated without killing their host) – were announced tomorrow.

There are manifest differences in the epidemiology of Aids and that of influenza, which go some way to explaining why the Great Epidemic was so swiftly forgotten. Being contagious, influenza was – and is – more easily transmitted; its trajectory through a population is more rapid. The fatal flu of 1918 came and went in a couple of years; it took only weeks to dispatch its victims. They had little time to reflect on their condition. The high-risk groups were the same as with most diseases – children and the old, the least articulate – rather than those in the prime of life (though Aids, of course, kills children too). This was just as well as, in Europe at least, death had already reaped its harvest of male adults in the trenches. There was no effective treatment for flu; and none of the confidence in scientific medicine that later successes in the treatment of infectious diseases bred in medical researchers. Although the 19th-century revolution in public health had already transformed the ecology of disease in Western countries, the 20th-century triumphs of curative medicine were yet to happen.

The triumphs of medicine, of antibiotics in particular, and the air of hubris they engendered in medical research are, of course, one reason for the unprecedented intensity of concern with Aids. The successful treatment of sexually transmitted diseases with antibiotics is generally acknowledged to have been, after oral contraception, the main factor in the post-war sexual revolution. Aids, though, has brought the sexual revolution up short, and, at the same time, in the public mind, delivered a blow to medical triumphalism. It has also, paradoxically or not, extended the hegemony of public health: sex now carries a statutory health warning. The apparatus of mass communications has been adapted from the task of fostering desires to that of curbing them. The medical establishment – in the form of the Health Education Authority in Britain – has recruited the public to an unusual degree in a programme of preventive sexual medicine, promulgating a form of hygiene analogous to that practised in the clinic. We are all health workers now: rubber gloves in the operating theatre; condoms in the bedroom. The ultimate transgression is to be without protection. The condom, barrier both to conception and to infection, is an emblem of this new dispensation: the triumph of the prophylactic.

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